Hemoptysis and Weight Loss in a Smoker

Hemoptysis and weight loss in a smoker

A 68-year-old woman is brought to the emergency room after *coughing up several tablespoons of bright red blood. For the previous 3 to 4 months, she has had a chronic nonproductive cough but no fevers. More recently, she has noticed some scant blood-streaked sputum. On review of her symptoms, she reports increased fatigue,*decreased appetite, and a 11 kg weight loss in the past 3 months. She denies chest pain, fever, chills, or night sweats. The patient has smoked one pack of cigarettes per day for the past 35 years. She drinks two martinis every day and has not had any significant medical illness. She worked in a library for 35 years and has no history of occupational exposures. She does not take any medication except for one aspirin per day. The patient is a thin woman who is mildly anxious, alert, and oriented. Her blood pressure is 150/90 mm Hg, heart rate 88 bpm, respiratory rate 16 breaths per minute, and temperature 36.5°C. Neck examination reveals no lymphadenopathy, thyromegaly, or carotid bruit. The chest has scattered rhonchi bilaterally, but there are no wheezes or crackles. Cardiovascular examination reveals a regular rate and rhythm, without rubs, gallops, or murmurs. The abdomen is benign with no hepatosplenomegaly. Examination of her extremities reveals no cyanosis; there is*finger clubbing. Neurologic examination is normal.

What is your next step? What is the most likely diagnosis?

Finger clubbing: loss of the angle between nail and nail fold. CFIM n°38 Hemoptysis

MECHANISMS • Neoplasms: Invasion of superficial mucosa and erosion of blood vessels; High vascular tumor with fragile walls

• Pulmonary venous hypertension: High Vasculitis pressure damage venous walls • Infection: Inflammation and repeated cough disrupts pulmonary vasculature • Vascular damage by vasculitis or pulmunary infarction MECHANISMS OF UNINTENTIONAL WEIGHT LOSS Thyroid hormones Catecholamines Cytokines

Energy balance

3-6 months

Malnutrition Universal Screening Tool (MUST)

HYPERTROPHIC OSTEOARTHROPATHY AND CLUBBING

Hypertrophic osteoarthropathy (HOA) is characterized by clubbing of digits and, in more advanced stages, by periosteal new-bone formation and synovial effusions. Bone changes in the distal extremities begin as periostitis followed by new bone formation. HOA may be primary or secondary associated with intrathoracic malignancies, suppurative and some hypoxemic lung and heart diseases.

HOA may be primary or secondary associated with intrathoracic malignancies, suppurative and some hypoxemic lung and heart diseases. Hemoptysis and weight loss in a smoker

What is your next step? What is the most likely diagnosis?

Finger clubbing: loss of the angle between nail and nail fold. CFIM n°38 Hemoptysis and weight loss in a smoker

A 68-year-old woman is brought to the emergency room after coughing up several tablespoons of bright red blood. For the previous 3 to 4 months, she has had a chronic nonproductive cough but no fevers. More recently, she has noticed some scant blood-streaked sputum. On review of her symptoms, she reports increased fatigue, decreased appetite, and a 11 kg weight loss in the past 3 months. She denies chest pain, fever, chills, or night sweats. The patient has smoked one pack of cigarettes per day for the past 35 years. She drinks two martinis every day and has not had any significant medical illness. She worked in a library for 35 years and has no history of occupational exposures. She does not take any medication except for one aspirin per day. The patient is a thin woman who is mildly anxious, alert, and oriented. Her blood pressure is 150/90 mm Hg, heart rate 88 bpm, respiratory rate 16 breaths per minute, and temperature 36.5°C. Neck examination reveals no lymphadenopathy, thyromegaly, or carotid bruit. The chest has scattered rhonchi bilaterally, but there are no wheezes or crackles. Cardiovascular examination reveals a regular rate and rhythm, without rubs, gallops, or murmurs. The abdomen is benign with no hepatosplenomegaly. Examination of her extremities reveals no cyanosis; there is finger clubbing. Neurologic examination is normal.

What is your next step? Chest imaging, either x-ray and CT scan. If abnormalities are seen, a biopsy procedure to establish a tissue diagnosis. In the meantime, she will benefit from rest and cough suppression to minimize her hemoptysis, which may be acutely life threatening, if massive bleeding occurs. What is the most likely diagnosis? Lung cancer

Finger clubbing: loss of the angle between nail and nail fold. CFIM n°38 Lung cancer is the leading cause of cancer deaths in both men and women.

* * * * (non-smokers) * *

* * * * * *

Radiologic Appearance of Lung Cancer. A wedge- shaped density in the middle lobe (a secondary). Also note a coin lesion at the right costophrenic angle. The sharp upper boundary of the middle lobe triangular mass is the middle lobe fissure. The right hilar structures are enlarged by metastases within the hilar lymph nodes.

A solitary pulmonary nodule is the most common radiographic presentation of lung cancer.

Cancer increases risk of atrial fibrillation

Acanthosis nigricans

Confusion and lethargy in a patient with lung cancer A 65-year-old white woman is brought to the ER by her family for increasing confusion and lethargy over the past week. She was recently diagnosed with limited stage small cell lung cancer but has not begun cancer treatment. She has not been febrile or had any other recent illnesses. She is not taking any medications. Her blood pressure is 136/82 mm Hg, heart rate is 84 bpm, and respiratory rate is 14 breaths per minute and unlabored. She is afebrile. On examination, she is an elderly appearing woman who is difficult to arouse and reacts only to painful stimuli. She is able to move her extremities without apparent motor deficits, and her deep tendon reflexes are decreased symmetrically. The Glasgow Coma Scale score was 8. The remainder of her examination is normal, with a normal jugular venous pressure and no extremity edema. You order some laboratory tests, which reveal the serum sodium level is 108 mmol/L, potassium 3.8 mmol/L, bicarbonate 24 mEq/L, blood urea nitrogen (BUN) 5 mg/dL, and creatinine 0.5 mg/dL. Serum osmolality is 220 mOsm/kg, and urine osmolality is 400 mOsm/kg. A computed tomographic (CT) scan of the brain shows no masses or hydrocephalus.

• What is the most likely diagnosis? • What is your next step in therapy? • What are the complications of therapy?

CFIM n° 5 Confusion and lethargy in a patient with lung cancer

A 65-year-old white woman is brought to the ER by her family for increasing confusion and lethargy over the past week. She was recently diagnosed with limited stage small cell lung cancer but has not begun cancer treatment. She has not been febrile or had any other recent illnesses. She is not taking any medications. Her blood pressure is 136/82 mm Hg, heart rate is 84 bpm, and respiratory rate is 14 breaths per minute and unlabored. She is afebrile. On examination, she is an elderly appearing woman who is difficult to arouse and reacts only to painful stimuli. She is able to move her extremities without apparent motor deficits, and her deep tendon reflexes are decreased symmetrically. The remainder of her examination is normal, with a normal jugular venous pressure and no extremity edema. You order some laboratory tests, which reveal the serum sodium level is 108 mmol/L, potassium 3.8 mmol/L, bicarbonate 24 mEq/L, blood urea nitrogen (BUN) 5 mg/dL, and creatinine 0.5 mg/dL. Serum osmolality is 220 mOsm/kg, and urine osmolality is 400 mOsm/kg. A computed tomographic (CT) scan of the brain shows no masses or hydrocephalus.

• What is the most likely diagnosis? Coma/lethargy secondary to severe hyponatremia, which is most likely caused by a paraneoplastic syndrome of inappropriate secretion of antidiuretic hormone (SIADH). • What is your next step in therapy? Treat the hyponatremia with hypertonic saline • What are the complications of therapy? Osmotic cerebral demyelination, also referred to as central pontine myelinolysis.

CFIM n° 5

HYPOVOLEMIA

HYPERVOLEMIA EUVOLEMIA

Nell’UE Samsca® (tolvaptan) è approvato unicamente per il trattamento di pazienti adulti con iponatriemia secondaria a sindrome da inappropriata secrezione di ormone antidiuretico (SIADH).

PATHOGENESIS OF HYPERVOLEMIC-HYPONATRAEMIA IN CIRRHOSIS AND HEARTH FAILURE

Heart RAAS failure SNS

DIFFERENTIATE BETWEEN: • DILUTIONAL HYPONATREMIA (nonosmotic AVP release, thirst) • DEPLETIONAL HYPONATREMIA (sodium-restricted diet, sodium losses: diuretics, diarrhea, ascites).

Nell’UE Samsca® (tolvaptan) è approvato unicamente per il trattamento di pazienti adulti con iponatriemia secondaria a sindrome da inappropriata secrezione di ormone antidiuretico (SIADH).

* Other treatment options, including loop diuretics, demeclocycline, urea, lithium, and removal of drugs that are known to cause hyponatremia, may be considered on a case-by-case basis. Specific treatment of the underlying disease should be started, when possible. HYPERTONIC SALINE

Chronic cough, night sweats and unintentional weigh loss A 62-year-old man is brought to the clinic for a*3-month history of unintentional weight loss (6 kg). His appetite has diminished, but he reports no vomiting or diarrhea. He does report some depressive symptoms since the death of his wife a year ago, at which time*he moved from Hong Kong to the United States to live with his daughter. He denies a smoking history. He complains of a 3-month history of *productive cough with greenish blood-streaked sputum.*Night sweats. He takes no medications regularly. On examination, his temperature is*38°C and respiratory rate is 16 breaths per minute. His neck has a normal thyroid gland and no cervical or supraclavicular lymphadenopathy. His chest has few scattered rales in the left mid-lung fields and a faint expiratory wheeze on the right. His heart rhythmis regular with no gallops or murmurs. His abdominal examination is benign, his rectal examination shows no masses, and his stool is negative for occult blood. His*chest x-ray shows cavitary lesion right higher lobe -black arrows- and parenchimal infiltrates -white arrows. .

What is the most likely diagnosis?

What is your next step?

CFIM n°31 Chronic cough, night sweats and unintentional weigh loss A 62-year-old man is brought to the clinic for a 3-month history of unintentional weight loss (6 kg). His appetite has diminished, but he reports no vomiting or diarrhea. He does report some depressive symptoms since the death of his wife a year ago, at which time he moved from Hong Kong to the United States to live with his daughter. He denies a smoking history. He complains of a 3-month history of productive cough with greenish blood-streaked sputum. Night sweats. He takes no medications regularly. On examination, his temperature is 38°C and respiratory rate is 16 breaths per minute. His neck has a normal thyroid gland and no cervical or supraclavicular lymphadenopathy. His chest has few scattered rales in the left mid-lung fields and a faint expiratory wheeze on the right. His heart rhythmis regular with no gallops or murmurs. His abdominal examination is benign, his rectal examination shows no masses, and his stool is negative for occult blood. His chest x-ray is shown in the Figure.

What is the most likely diagnosis? Pulmonary tuberculosis. A chest radiograph is essential in helping to establish the diagnosis. This chest x-ray is highly suggestive of TB (cavitary lesion right higher lobe -black arrows- and parenchimal infiltrates -white arrows), but many other diseases may cause cavitary lung lesions, including other infections and malignancies.

What is your next step? Refer him to the hospital for admission so that serial sputum samples can be collected for identification of the organism, and for culture and sensitivities to guide antimicrobial therapy. If the sputum samples do not reveal acid-fast organisms, then further testing, such as bronchoscopy, may be needed to rule out malignancy. CFIM n°31 Tuberculosis incidence rates per 100,000 population in 2013 10%

ACTIVE TUBERCULOSIS • Pulmonary (90% of cases): cough, hemoptysis,, unintentional weight loss, fever. • Extra-pulmonary (15–20% of cases) more common in immunosuppressed persons (HIV), in order of frequency (aerobic bacteria): lymph nodes, pleura, genitourinary tract, bones and joints, meninges, peritoneum, and pericardium. • Miliary (disseminated) tuberculosis (10% of extra-pulmonary cases).

Pulmonary Tuberculosis Tuberculosis is a bacterial infection caused by the acid-fast bacillus (AFB) (bacilli acido-alcol resistenti, BAAR) M tuberculosis, which usually is transmitted through airborne spread of droplets from infected patients with pulmonary TB. The vast majority of cases occur in developing countries, but a resurgence of cases in the United States occurred during the mid-1980s as a consequence of various factors, including human immunodeficiency virus (HIV) infection. Untreated disease can have a 1-year mortality rate of 33% and a 5-year mortality rate as high as 50%. • Often seen in children, primary pulmonary TB usually affects the middle and lower lung zones. Lesions form in the periphery with hilar and paratracheal lymphadenopathy. Granulomatous lesions are caused by the inflammatory response of lymphocytes and macrophages. The center of the lesion may become necrotic (caseous necrosis) and liquefied, forming a cavity. Healed lesions are called Ghon lesions. Most patients exposed to M tuberculosis do not manifest clinical symptoms, but they may have a latent infection. • Years later, frequently during times of stress or immunosuppression, TB may reactivate and become symptomatic. Reactivation TB usually involves the apical and posterior segments of the upper lobes or the superior segments of the lower lobes of the lungs. The course may be rapid (weeks to months), chronic and slowly progressive (“consumption”), or spontaneously remit. Signs and symptoms are nonspecific and subacute, including fever, night sweats, malaise, weight loss, and anorexia. The cough usually is productive of purulent sputum and sometimes streaked with blood. A lesion may erode into a vessel, causing massive hemoptysis. Rasmussen aneurysm is the rupture of a dilated vessel in a cavity. Physical findings can include fever, wasting, rales and rhonchi (if there is a partial bronchial obstruction), pallor, or finger clubbing from hypoxia. Possible laboratory abnormalities are leukocytosis, anemia, and hyponatremia secondary to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Extrapulmonary Tuberculosis The sites, in order of decreasing frequency of occurrence, are the lymph nodes, pleura, genitourinary tract, bones and joints, meninges, and peritoneum. • Tuberculosis lymphadenitis is common in HIV-infected patients, children, and nonwhite women and generally is painless adenopathy. • Tuberculous pleuritis can have an exudative effusion but may require pleural biopsy for diagnosis. • Genitourinary TB can be asymptomatic or have local symptoms such as dysuria, hematuria, and urinary frequency. It is characterized by the finding of leukocytes in the urine but negative bacterial cultures—“sterile pyuria.” • Skeletal TB affects weight-bearing joints, whereas Pott disease involves the spine. • Tuberculous meningitis usually has cerebrospinal fluid with high protein, a lymphocyte predominance (or neutrophils in early infection), and low glucose level. Adjunctive glucocorticoids may improve the treatment response in TB meningitis. • Miliary TB refers to hematogenously disseminated tuberculosis, and describes the radiographic or pathologic finding of 1- to 2-mm granulomas that resemble millet seeds (hence the name). Adrenal involvement is common in military TB, and may cause adrenal insufficiency. Diagnosis The diagnosis of TB is made by combining the history and clinical picture with AFB stains or culture of a specimen (smear or tissue biopsy). When pulmonary TB is suspected, three samples of early morning sputum should be obtained while the patient is in isolation. Biopsy material should not be put in formaldehyde. Cultures may take from 4 to 8 weeks on ordinary solid media or 2 to 3 weeks on liquid media. Tuberculosis cases should be reported to the local public health department. Purified protein derivative (PPD), or tuberculin, skin testing is useful for screening for latent TB infection but has a limited role in diagnosing active infection because of frequent false-negative results in this setting. A positive PPD is defined by induration of at least 5 mm after 48 to 72 hours. Interferon-gamma release assays (IGRAs) are new diagnostic tools for latent tuberculosis. They are in vitro blood tests of cell-mediated immune response to M tuberculosis and measure T-cell release of interferon-gamma (IFN-gamma) following stimulation by TB antigens. The Centers for Disease Control and Prevention (CDC) recommend that such tests can be used in place of tuberculin skin testing. IGRAs are preferred for patients with history of Bacillus Calmette-Guérin (BCG) vaccination (it is not affected by BCG). The most commonly used IGRAs are the Quantiferon TB Gold assay and the T-SPOT TB assay.

Treatment The probable resistance pattern of the TB organism, based on the country of origin, may help to guide treatment. For individuals from areas with low drug resistance, therapy generally starts with a 2-month course of four-drug treatment with isoniazid (INH), rifampin, pyrazinamide, and ethambutol, followed by 4 months of INH and rifampin. Multiple drugs are used to avoid resistance. Directly observed treatment (watching patients take the medication) should be instituted in all patients in this phase. Pyridoxine is frequently added to the regimen to prevent peripheral neuropathy. Drug resistance or intolerable side effects may require alternate therapy. Toxicity for which patients must be monitored includes hepatitis, hyperuricemia, and thrombocytopenia. Treatment failure is defined by positive cultures after 3 months or positive AFB stains after 5 months and should be treated by adding two more drugs. Latent TB infection should be treated with INH for 9 months, with the goal of preventing reactivation TB later in life. MRI of culture-confirmed renal tuberculosis. Coronary plane: coronal sections showing several renal lesions in both the cortical and the medullary tissues of the right kidney.

CT scan demonstrating destruction of the right pedicle of T10 due to Pott’s disease. The patient, a 70- year-old Asian woman, presented with back pain and weight loss and had biopsy- proven tuberculosis.

Fever, dyspnea and oral candidiasis in a HIV infected patient A 32-year-old man infected with human immunodeficiency virus (HIV), whose last CD4 count is unknown, presents to the ER with a fever of 39°C. He was diagnosed with*HIV infection approximately 3 years ago when he presented to his doctor with*oral thrush. He was offered*highly active antiretroviral therapy (HAART) and stayed on this regimen until approximately 10 months ago, when he lost his job and insurance and could no longer pay for the drugs and discontinued all treatment. He has felt more “run down” recently. For the last 2 to 3 weeks he has had*fever and a nonproductive cough, and he has felt short of breath with mild exertion, such as when cleaning his house. On examination his blood pressure is 134/82 mm Hg,*pulse is 110 bpm, and respiratory rate is 28 breaths per minute. His oxygen saturation on room air at rest is 89% but drops to 80% when he walks 100 feet, and his breathing becomes quite labored.*His lungs are clear to auscultation, but*white patches cover his buccal mucosa. Otherwise, his examination is unremarkable. Laboratory testing shows a leukocyte count of 2800 cells/mm3. CD4 counts of 160 cells/mm3. Serum lactic dehydrogenase (LDH) is 540 U/L* (normal 140-280 U/L). His chest radiograph shows diffuse bilateral pulmonary infiltrate.

CFIM n°7 Fever, dyspnea and oral candidiasis in a HIV infected patient A 32-year-old man infected with human immunodeficiency virus (HIV), whose last CD4 count is unknown, presents to the ER with a fever of 39°C. He was diagnosed with*HIV infection approximately 3 years ago when he presented to his doctor with*oral thrush. He was offered*highly active antiretroviral therapy (HAART) and stayed on this regimen until approximately 10 months ago, when he lost his job and insurance and could no longer pay for the drugs and discontinued all treatment. He has felt more “run down” recently. For the last 2 to 3 weeks he has had*fever and a nonproductive cough, and he has felt short of breath with mild exertion, such as when cleaning his house. On examination his blood pressure is 134/82 mm Hg,*pulse is 110 bpm, and respiratory rate is 28 breaths per minute. His oxygen saturation on room air at rest is 89% but drops to 80% when he walks 100 feet, and his breathing becomes quite labored.*His lungs are clear to auscultation, but*white patches cover his buccal mucosa. Otherwise, his examination is unremarkable. Laboratory testing shows a leukocyte count of 2800 cells/mm3. CD4 counts of 160 cells/mm3. Serum lactic dehydrogenase (LDH) is 540 U/L* (normal 140-280 U/L). His chest radiograph shows diffuse bilateral pulmonary infiltrate.

What is the most likely diagnosis? Acquired immunodeficiency syndrome (AIDS) and probable Pneumocystis jirovecii pneumonia (formerly Pneumocystis carinii): a unicellular fungus that causes pneumonia in immunocompromised patients, especially those with HIV and CD4 counts less than 200 cells/mm3. What is your next step? stabilize the patient, who is tachypneic and hypoxic but is in only mild distress and is hemodynamically stable. Therefore, there is time to further evaluate him. An arterial blood gas measurement can be obtained to quantify his degree of hypoxemia, as it will impact the treatment. What other diagnoses should be considered? In patients with AIDS, other opportunistic infections must be considered. Other respiratory infections, such as tuberculosis, atypical mycobacteria, cryptococcosis, and disseminated histoplasmosis. CFIM n°7

25 AIDS-defining illnesses 1. Candidiasis of the bronchi, trachea, or lungs [(but NOT the mouth (thrush)] 2. Candidiasis of the esophagus 3. Cervical cancer, invasive 4. Coccidioidomycosis, disseminated or extrapulmonary 5. Cryptococcosis, extrapulmonary 6. Cryptosporidiosis, chronic intestinal (greater than one month's duration) 7. Cytomegalovirus disease (other than liver, spleen, or nodes) 8. Cytomegalovirus retinitis (with loss of vision) 9. Encephalopathy, HIV related 10. Herpes simplex: chronic ulcer(s) (more than 1 month in duration); or bronchitis, pneumonitis, or esophagitis 11. Histoplasmosis, disseminated or extrapulmonary 12. Isosporiasis, chronic intestinal (more than 1 month in duration) 13. Kaposi sarcoma 14. Lymphoma, Burkitt's (or equivalent term) 15. Lymphoma, immunoblastic (or equivalent term) 16. Lymphoma, primary, of brain 17. Mycobacterium avium complex or M kansasii, disseminated or extrapulmonary 18. Mycobacterium tuberculosis, any site (pulmonary or extrapulmonary) 19. Mycobacterium, other species or unidentified species, disseminated or extrapulmonary 20. Pneumocystis jiroveci pneumonia 21. Pneumonia, recurrent 22. Progressive multifocal leukoencephalopathy 23. Salmonella septicemia, recurrent 24. Toxoplasmosis of brain 25. Wasting syndrome due to HIV Revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. Morbidity and Mortality Weekly Report, December 18, 1992/41 (RR-17), 1993

Sexually transmitted infections/diseases (STI/STD)

• Top 10 STIS: genital warts, chlamydia, genital herpes, gonorrhoea, HIV, hepatitis B & C, pubic lice, syphilis, trichomonas

• History Ask about timing of last intercourse; contraceptive method; sexual contacts; duration of relationship; sexual practices/orientations; past STI; menstrual and medical history; antimicrobial therapy. Are sexual negotiation skills up to scratch?

• Examination Detailed examination of genitalia including inguinal nodes and pubic hair. Scrotum, subpreputial space, and male urethra. PR examination and proctoscopy (if indicated); PV and speculum examination.

• Signs Vaginal/urethral discharge (p418), genital lesions: herpes (p400); syphilis (p431); Chlamydia (BOX); genital warts (OHCS p599); salpingitis (OHCS p286); lice (OHCS p608).

• Tests Refer to GUM clinic. Urine: dipstick and MSU/MC&S. Ulcers: swabs for HSV culture (viral transport medium) and dark ground microscopy for syphilis (T. pallidum). Urethral smear for Gram stain/culture for N. gonorrhoeae (send quickly to lab in Stuart’s medium); urethral swab for Chlamydia (free tests also available from UK chemists, see BOX). High vaginal or swab in Stuart’s medium for microscopy/culture (Candida, Gardnerella vaginalis, anaerobes, Trichomonas vaginalis); special endocervical swab for Chlamydia trachomatis. Chlamydia (an obligate intracellular bacteria) is the trickiest STD to diagnose as it is asymptomatic, difficult to culture, and serology may be unhelpful as it cross-reacts with C. pneumoniae. Urine ligase chain reaction and PCR are quite good screening tests, with sensitivity >90%. Other tests: include Chlamydia antigen and nucleic acid probe assays. 280 Blood tests: Syphilis, hepatitis, and HIV serology after counselling.

• Follow-up At 1wk and 3 months, with repeat smears, cultures, and syphilis serology. Gender Population Routine screening recommendation Screening frequency STI screening recommendations by Genital chlamydia Annually gender and population Age <25 years Genital gonorrhea Annually HIV At least once Age ≥25 years HIV At least once Genital chlamydia First trimester (if <25 years or at increased risk*) Genital gonorrhea First trimester (if <25 years or at increased risk*) Pregnant Syphilis First trimester Women HIV First trimester HBV First trimester HAV: hepatitis A virus; HBV: hepatitis B virus; HCV: hepatitis C virus; Genital chlamydia Annually MSW: men who have sex only with women; MSM: men who have Genital gonorrhea Annually sex with men; STI: sexually transmitted infection. * Increased risk Genital trichomoniasis Annually factors for gonorrhea, chlamydia, and trichomoniasis in women HIV-infected include prior infection, particularly in the preceding 24 months; Syphilis Annually multiple sex partners within the past year; suspicion that a recent HBV First visit partner may have had concurrent partners; new sex partner in the HCV First visit past 3 months; exchanging sex for drugs or money within the past year; residing in an area of high STI prevalence. ¶ Increased risk HIV-uninfected MSW HIV At least once factors for gonorrhea and chlamydia in MSW include an infection in the preceding 24 months. Δ Increased risk factors for gonorrhea, Genital chlamydia At least annually chlamydia, syphilis, and HIV among MSM include multiple or anonymous partners; intravenous drug use; sex in conjunction with Rectal chlamydia (if exposed) At least annually illicit drug use, including methamphetamines; sex partners who Genital gonorrhea At least annually engage in these activities. Increased risk factors for hepatitis C Rectal gonorrhea (if exposed) At least annually infection among MSM include HIV infection, high community HCV Pharyngeal gonorrhea (if exposed) At least annually HIV-uninfected MSM prevalence and incidence, high-risk sexual behaviors, and Syphilis At least annually concomitant ulcerative STIs or STI-related proctitis HIV At least annually HAV First visit HBV First visit HCV At least once Men Genital chlamydia Annually Genital gonorrhea Annually HIV-infected MSW Syphilis Annually HBV First visit HCV First visit Genital chlamydia At least annually Rectal chlamydia (if exposed) At least annually Genital gonorrhea At least annually Rectal gonorrhea (if exposed) At least annually HIV-infected MSM Pharyngeal gonorrhea (if exposed) At least annually Syphilis At least annually HAV First visit HBV First visit HCV At least annually

Condylomata acuminata (CA), also known as anogenital warts, are a manifestation of anogenital human papillomavirus (HPV) infection. Anogenital warts are almost always acquired through sexual activity. Although CA may spontaneously resolve, resolution may take months and is unpredictable. First-line therapies include cryotherapy, surgical excision, electrosurgery, and carbon dioxide laser therapy. Sexual activity is the primary risk factor for the development of CA. Vaccination against HPV can prevent the acquisition of CA. Chlamydia trachomatis infections

• Infection with C. trachomatis is common worldwide; in the US, it is the most frequently reported bacterial infection. Prevalence is consistently highest among young women. Risk factors include sexual behavior. Because only the minority of C. trachomatis infections present as syndromes, screening of asymptomatic persons plays a critical role in detecting the majority of infections. • In women, C. trachomatis most commonly affects the cervix. The majority of infected women are asymptomatic, although some may present with the typical findings of cervicitis, including vaginal discharge, abnormal vaginal bleeding, and purulent endocervical discharge on exam. The most concerning complication of untreated cervical chlamydial infection is pelvic inflammatory disease, which in turn can lead to infertility, ectopic pregnancy, or chronic pelvic pain. • In men, C. trachomatis is a common cause of nongonococcal urethritis. The majority of infected men are asymptomatic. When present, symptoms include a mucoid or watery urethral discharge and dysuria. C. trachomatis is a frequent cause of acute epididymitis in men younger than 35 years old and may be an etiology in some cases of chronic prostatitis. • The serovars of C. trachomatis that cause lymphogranuloma venereum have been increasingly reported in cases of proctitis in men who have sex with men. These cases tend to be symptomatic, with anorectal pain, discharge, and tenesmus, and can be mistaken for inflammatory bowel disease. • The diagnostic test of choice for chlamydial infection of the genitourinary tract is nucleic acid amplification testing (NAAT) of vaginal swabs for women or urine for men. Many laboratories have also validated NAAT on rectal swabs to diagnose chlamydial proctitis. • Any sexually active individual with signs and symptoms consistent with the clinical syndromes associated with chlamydia and patients with documented gonococcal infection should undergo diagnostic testing for C. trachomatis. Because the majority of chlamydial infections are asymptomatic, routine screening with NAAT should be offered to sexually active patients at high risk of infection and complications of chlamydia. • N. gonorrhoeae not only causes similar clinical syndromes as C. trachomatis but also coexists in a significant proportion of patients with chlamydial infection. Thus, any testing for C. trachomatis should also prompt testing for N. gonorrhoeae. • Infants who are born vaginally to mothers with untreated genital Chlamydia trachomatis (C. trachomatis) infection are at risk for developing C. trachomatis conjunctivitis (15 to 50 percent) and/or pneumonia (5 to 20 percent). • Antimicrobial agents that have excellent activity against C. trachomatis include doxycycline (a tetracycline) and azithromycin (a macrolide).

Chlamydia: Rates of reported cases by age and sex, United States, 2016

Mucopurulent discharge is visible coming from the os in a patient with Chlamydia cervicitis. The cervix is erythematous and friable Herpes simplex virus (HSV)

Herpes simplex virus (HSV) is a common sexually transmitted disease worldwide. HSV-1 more commonly causes Herpes Labialis while HSV-2 more commonly causes Genital Herpes. The clinical designations of genital HSV infection are: primary, nonprimary first episode, and recurrent infection. Primary infection refers to infection in a patient without preexisting antibodies to either HSV-1 or HSV-2. Nonprimary first episode infection refers to the acquisition of genital HSV-1 in a patient with preexisting antibodies to the alternate serotype. Recurrent infection refers to reactivation of genital HSV in which the HSV type recovered in the lesion is the same type as those seen on serologic testing..) Transmission of HSV may occur quickly in new sexual relationships. The clinical manifestations of primary genital HSV infection are highly variable. The initial presentation can be severe with painful genital ulcers and constitutional symptoms; in other patients, the infection may be mild or entirely asymptomatic. Nonprimary infection is associated with fewer lesions and less systemic symptoms than primary infection, presumably because antibodies against one HSV type offer some protection against the other. Extragenital complications, like aseptic meningitis, occur in a minority of patients who present with primary HSV infection. In immunosuppressed patients, most genital HSV infections occurring in immunosuppressed adults reflect reactivation syndromes. The diagnosis of HSV infection can be confirmed by polymerase chain reaction (PCR), viral culture, and type-specific serologic tests. The choice of test varies with the clinical presentation. PCR-based assays or culture are preferred for active genital lesions; serologic testing is the preferred method in patients without active disease. PCR is the most sensitive test available, but is limited by cost. Routine screening for HSV-1 or HSV-2 infection by serologic testing is not recommended.